Don’t Bug Me!

Now, where was I?

Yes. Assessment.

The one-size-fits-all assessment found in most EDs today does not work for mental health patients. At least, not entirely. Yes, a perusal of this completed and often quite lengthy form will fill me in on blood pressure, pulse and temperature. It will let me know about medications taken at home. It will list previous medical diagnoses and oftentimes who is treating those illnesses. It will talk about elimination patterns and intake. It will assure me that the bedrails are in the proper position to prevent falls. All important items to address in an environment that is geared towards rapid global assessment in a safe environment.

We joked, again, in a teleconferenced staff meeting yesterday afternoon about the fact that these assessments will let me know what the patient’s TB testing status is for the last ten years, but will sometimes give me absolutely no clue as to the number of previous serious suicide attempts, even though the consult sent my way asks for an assessment of suicide risk.

Forms follow function.

Now some ED staff members, especially those wonderful, insightful ED nurses who are my lifeline to what’s really going on with the patient I am about to interview, ask probing and spot-on questions that get to the core reason the person arrived at the hospital. That’s great. Others, stressed to the max, covering too many really sick patients, and pulling their fifth long shift in a row, just don’t have the wherewithal to dig deep for some of the things I’d like to be told or made aware of as a matter of course. I’m not blaming them. It’s just a fact.

I’ll give you an example. A few weeks ago, I was going to see a young man who had supposedly made threats to kill himself and was very paranoid about family members at home. Pretty straight forward, right? I reviewed the records, called the nurse working with this man, asked her how he had been doing in the ED so far, and what her personal assessment of his current symptoms and status was.

She told me that he had been very quiet (spoiler alert-this is usually not good given the history I started you off with just now), a model patient, and had given them no trouble at all. No, she had not heard anything from him about delusions (she had not asked), did not think he had a plan to kill himself, and felt that he would probably be safe to discharge home (one of the primary, if oft-unspoken goals of an emergency room consult, truth be told).

I thanked her for her insights, got the patient on the screen and asked what brought him to the hospital. My first clue was his assertion that the federal government had placed a bug in the back of his head that was tracking his every move, that there were helicopters outside his house, and that he had made very detailed plans that he felt would lead to a successful suicide attempt when he got home. Oh, yes, he had indeed been very quiet and no trouble at all in the ED. He was not acting out, had not required IM medications or restraints, and was not taking up too many of the ED’s resources. The problem? He was very quietly psychotic as hell. I recommended admision for his safety and to treat his “obvious” symptoms. Obvious only if you took the time to really look for them and assess them.

Lastly, all that glitters is not gold. All that hallucinates is not schizophrenia. All that looks sad and flat is not depression. This is a real pet peeve of mine. One of the reasons doctors with medical school and residency training make good psychiatrists is that they know what else to look for. This is  not a cookbook specialty (Oh yeah. DSM-5. My copy has shipped this week and should be here soon. Please don’t get me started. That’s another series of posts for another day, you can be sure of that) and things don’t usually line up neatly as they should. As a matter of fact, in the ED they almost never do. You have to be curious, ask the right questions, dig a little, and when you hear hoofbeats sometimes look for zebras and not the conventional horses as you were taught in medical school.

I have seen hypothyroidism show up to the party as “major depression”, an undiagnosed brain tunor cause “schizophrenia”, and “panic attacks” that were due to hypoxia. One of the most challenging and fun things about psychiatry for me, and ED telepsychiatry is certainly part of it, is that my patients don’t always read the book. Granted, they read it more these days than they used to, but they don’t often read beyond the outlines or the first few paragraphs.

Diagnosis is a challenge. Assessment done right, and thoroughly, is a huge part of that.

What shall we talk about next? Hmm. Maybe what Tom Petty and the Heartbreakers allude to in their song. You know the one I’m talking about.

The Waiting (is the hardest part).

Enjoy. I’ll be back soon.

9 thoughts on “Don’t Bug Me!

  1. One of my friends was in the local, high quality Psychiatric Hospital, admitted on a late Friday night for being ‘unwilling to move’ –spent the weekend ‘refusing to move’ and the staff that was normally there was not — some temps were there (never did hear the story on that one? conference -employment glitch? who knows — but they’d read ED report and were quite rude to her about her refusal to move). Regular staff arrives Monday morning and the psychiatrist comes walking in, and starts to talk to her and after 15 minutes tells her she’s going to be just fine. An hour later an IV is being inserted –and a neurologist is there overseeing a tensilon test –she had Myasthenia Gravis (which is how we met). My initial diagnosis was “being a baby about being a new mother” (on paper –post partum depression)—

    Unfortunately, having worked as a new patient educator for 3 years I heard more horror stories of psychiatric misdiagnosis (particularly for women) than accurate diagnosis. We Zebra’s love doctor’s who believe in our existence ;)

    DSM-V –cannot wait to read your thoughts on that ….

  2. MS is another one that sometimes takes years to diagnose.
    Just got the email that my DSM-5 has shipped. Guess I’ll be slogging through 900+ pages soon!

  3. MS, MG, Lupus, RA, Crohns — spend any time on social media and you’ll see horror stories of initial diagnosis being psychiatric.
    My confusion has been, as a student –having it drilled into me — before giving a diagnosis from the DSM –make sure a medical diagnosis has been ruled out (which, for me, obviously means they are seeing a good quality physician) and yet, so often the medical community is giving a psychiatric diagnosis FIRST before a medical diagnosis …
    Every time I’ve asked the question of how to resolve this — my professors, without fail, simply say “we are not all on the same page, we are not even reading the same text books.”
    A slightly dissatisfactory answer. :(

  4. To me, it’s a matter of doing a good medical history and physical assessment or making sure someone else has done it before defaulting to a major, significant psychiatric diagnosis.

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